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Show Immunization in the Acute Care Setting: Pneumonia Prevention in Utah Elderly by Juli A. Antonow, M.D., M.H.A. and Michael P. Silver, M.P.H. Problem Statement-Pneumonia in Utah In 1995 and 1996, pneumonia and influenza together ranked sixth nationally among the leading causes of death; more than 90% of these deaths were in elderly adults (>65 years of age) (CDC, October 1997). In Utah, the ranking was fifth in 1996 with a rate of 23.7 deaths per 100,000 due to pneumonia and influenza compared to a national rate of 31.1 (Utah Department of Health, 1996). There were 475 deaths in Utah in 1996 due to pneumonia and influenza; 423 (89%) were in persons aged 65 years and above (Utah Department of Health, 1996). That year, in a population of approximately 170,000 Utah Medicare beneficiaries aged 65 and over, 5.7% (n=2381, Table 1) of all Medicare admissions to Utah acute care facilities were for a pneumonia-related principal diagnosis. This represents, with allowed charges paid to hospitals of $5,400 per case, $12,800,000 in costs to Medicare (not including reimbursement to physicians by Medicare). Utah Medicare beneficiaries admitted to acute care facilities for pneumonia in 1996 experienced 7.2% inpatient mortality, with mortality rising to 14.3% at 30 days post-discharge (Medicare Part A billing data analysis by Healthlnsight, unpublished). In Utah, pneumonia is also an important rural health issue. Ambulatory care sensitive (ACS) hospitalizations are felt to be avoidable with optimal preventive care and early disease management in the outpatient setting. ACS hospitalization rates for respiratory conditions (including pneumonia) for Medicare beneficiaries in rural Utah counties indicate statistically significantly higher hospitalization rates compared to urban counties for a 5 year period (1990-94) (Silver, Babitz and Magill, 1997). The authors speculate that barriers in access to preventive care in rural Utah may contribute to excess hospitalizations for pneumonia. Preventable Pneumonia Etiologies Streptococcus pneumoniae fpneumo-coccus), a bacteria, accounts for an estimated 500,000 cases of pneumonia yearly in the United States. Adults > 65 years are at increased risk; adults with compromised immunity and chronic medical conditions are at even greater risk (CDC. April 1997). Influenza A viruses cause yearly seasonal epidemics. The elderly and those with underlying health conditions are at two-to-fivefold greater risk from influenza complications such as pneumonia requiring hospitalization. Estimated influenza-associated deaths ranged from 20,000-40,000 during each of 10 influenza epidemics from 1972-1991. Influenza-associated deaths result from pneumonia or by exacerbation of underlying cardiopulmonary and chronic conditions, more common in the elderly (CDC, May 1996). Vaccines are available which are effective in the prevention of these two etiologies for pneumonia in the elderly. Table 1. Medicare Part A-Derived Statistics on Utah Medicare Beneficiaries* 1993 1994 1995 1996 Utah Medicare beneficiaries age 65+ (with Medicare Part A coverage 7/l/9x) 158,848 162,669 166,209 169,385 Number of hospitalizations (Utah facilities, Medicare beneficiaries age 65+, any state of residence, any diagnosis) 38,988 38,777 40,943 42,128 Number of Utah Medicare beneficiaries age 65+ hospitalized 25,586 25,554 26,650 27,584 Number of pneumonia admissions (Utah hospitals, Utah Medicare beneficiaries age 65+) 2,403 2,159 2,529 2,381 Percent pneumonia admissions discharged alive followed within one year (and after 30 days) by another pneumonia admission (age 65+, overall=10.2%) 9.9% 9.3% 11.1% 10.3% * Each admission with a live discharge counts as a separate event towards the total readmission percent, even if a patient has more than one readmission for a pneumonia-related condition. 57 |